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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604444
Report Date: 06/26/2025
Date Signed: 06/26/2025 02:02:08 PM

Document Has Been Signed on 06/26/2025 02:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604444
ADMINISTRATOR/
DIRECTOR:		MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:1533 N. STANLEY AVE.TELEPHONE:
(323) 969-0316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
06/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Brian RosalesTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 06/26/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual inspection visit to the facility. LPA met with the Administrator and reason for the visit was discussed. Facility is licensed as a single-story residence, six (6) non-Ambulatory, of which, three (3) may be bedridden. Hospice waiver for six (6). Facility has six (6) private resident bedrooms and four (4) bathrooms.

At 10:15 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted in the bathroom and throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F., within the required range. Side door is located west of house which exits to the back yard. An approved Mitigation and Infection Control plan is on file. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/25/2025.

Fire Detection/Protection system is present at facility. Multiple smoke/carbon monoxide detectors are installed, hardwired and interconnected. Detectors were tested and function properly. Two (2) fire extinguishers, located in Kitchen and Hallway, are fully charged, with inspection service date: 03/04/2025.

[LIC 9099-C] Continued-
Eva MillerTELEPHONE: (818) -596-4373
Raymond ComerTELEPHONE: 818-401-8655
DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604444
VISIT DATE: 06/26/2025
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KITCHEN area is clean and clear of clutter. LPA observed refrigerator, microwave, stove/oven, dishwasher and sink to be operational. Knives/Sharps are stored in a locked top kitchen drawer inaccessible to residents. Plates, cups, utensils, and two-day supply of perishable food is properly stored and labeled. A seven day supply of nonperishable food is located in detached garage and properly stored. Dish Soap, cleaning solutions, and toxins are stored in locked lower cabinet underneath the kitchen sink.

Medications are stored in a secured medications cart in dining room area and are inaccessible to residents. A First Aid kit is accessible and stored in a dining room area cabinet. Medications are listed in centrally stored medication cart and destruction record log.

Laundry area is located and secured in hallway storage compartment near the kitchen. Laundry soaps and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and night stand.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 113.5°F. Within the required range.

Garage is detached from house and observed to be locked and inaccessible to residents. Garage is also used as storage for water, PPE supplies, etc.

Outdoor (backyard) area observed to have a shaded patio, with table, and sufficient seating for residents and visitors. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered; there are no bodies of water in the facility.

Resident records: LPA observed records stored in a locked and secured hallway closet, inaccessible to residents. Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be current and complete.



[LIC 9099-C] Continued-
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604444
VISIT DATE: 06/26/2025
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Staff records: LPA observed records stored in a locked and secured hallway closet, inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current.

There were no health and safety hazards observed during the inspection. Exit interview conducted and a copy of this report was given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
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